People Who Inject Drugs and PrEP Prescribing
Providers and clinical staff who are interested in providing treatment and care to individuals diagnosed with Hepatitis C (providers, nursing, behavioral health, linkage navigators, front desk/scheduling, admin, etc.).
- List currently available forms of PrEP and identify which have been approved for People Who Inject Drugs.
- Define PrEP in the context of injection drug use and its associated challenges and opportunities.
- Communicate how the Affordable Care Act establishes access to preventative services without cost-sharing.
- Help clients determine if PrEP would work for them and discuss other HIV prevention strategies.
Professional Practice Gap - National
Hepatitis C virus (HCV) infection is a blood-borne infectious disease that causes substantial liver-related morbidity and an increased risk of liver cancer and liver-related death. HCV is often known as a “silent disease,” as there are few noticeable symptoms, especially in early-stage infection. Because of this, many individuals are unaware of their HCV until more serious, late-stage complications arise. Treatment is available for HCV, with success measured by the sustained viral response (SVR) rate at 12 to 24 weeks post treatment (i.e., no detectable virus). Prior to 2014, an average of 48 to 70% of people achieved SVR with the available therapies; however, recent advances in therapeutic medications increased SVR rates to more than 95% in 2018. Achieving SVR can reverse the effects of early-stage fibrosis and slow the progression of cirrhosis to decompensation or hepatocellular carcinoma (HCC). This reduces liver-related mortality by 20-fold and all-cause mortality by 4-fold. Transmission of HCV can be prevented by avoiding direct exposure to contaminated blood or blood products, including objects that may have come in contact with contaminated blood, such as syringes and other drug paraphernalia.
Over the last 14 years, the HCV epidemic has drastically changed in the U.S. Originally a disease affecting “baby boomers” (people born between 1945 and 1965), HCV has reemerged as a syndemic with opioid use and overdoses, methamphetamine use, and HIV. In 2010, approximately 3.5 million Americans were living with chronic HCV. According to CDC data, HCV now kills more Americans than any other infectious disease. In addition, HCV is the leading cause of cirrhosis and liver cancer, and the most common reason for liver transplantation in the U.S. In 2013, deaths from HCV-related causes surpassed the total combined numbers of deaths from 60 other infectious diseases reported to the CDC, including HIV and tuberculosis. In 2014, HCV-related deaths reached an all-time high with more than 19,600 deaths reported. At the same time, there has been a marked simultaneous increase in the number of people newly diagnosed with HCV across the US, particularly among people with a history of injection drug use. The U.S. experienced marked increases in hospital admissions for acute HCV and for opioid injection between 2004 and 2014, with the number of people newly diagnosed with HCV more than doubling between 2010 and 2014.
National-level programs to control the burden of HCV have focused primarily on the older cohort of people with HCV. These programs include screening for HCV in the baby-boomer cohort (born 1945 to 1965) and programs offered through the Veteran’s Administration (VA) to diagnose and cure all veterans with HCV. Despite these efforts, barriers to treatment still exist at the state Medicaid level, as evidenced in many states by restrictions on treatment, including fibrosis scarring requirements that preclude treatment for people with early-stage liver disease. Universal procedures exist to prevent HCV transmission in medical settings across the U.S. (though localized outbreaks may still occur when procedures fail). However, the recent opioid crisis combined with increased methamphetamine usage in some parts of the country present new challenges for HCV prevention efforts. At present, policies to prevent transmission among drug users are entirely state-specific, and in many states, these policies simply do not exist.
Professional Practice Gap - Iowa
At the beginning of 2017, there were 26,900 Iowans with chronic HCV (HCV RNA+ viremic infections) in Iowa. Approximately 59% of people with chronic HCV were previously diagnosed (n= 15,900), with around 1,500 people being diagnosed annually, and 8% of people with diagnosed HCV (n=2,200) being initiated on treatment annually. There were an estimated 870 people acquiring HCV annually, an incidence rate of 57.8 per 100,000 in 2017. In addition,
- 52% of people with chronic HCV were in the 1945 to 1965 birth cohort*
- 14% of people with chronic HCV were women of child bearing age*
- 4% of people with chronic HCV were people who inject drugs*
- The number of people with chronic HCV in prisons was unknown
- The number of people with chronic HCV in Medicaid was unknown
*Percentages do not sum to 100% because overlap exists across groups and not all subpopulations are considered here.
Bureau of HIV, STD, and Hepatitis, Iowa Department of Public Health
- MD: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Iowa Medical Society (IMS) through the joint providership of Des Moines University (DMU) and the Iowa Primary Care Association. DMU is accredited by IMS to provide continuing medical education for physicians. DMU designates this live, online activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
- DO: Des Moines University (DMU) is accredited by the American Osteopathic Association (AOA) to provide osteopathic continuing medical education for physicians. DMU designates this activity for a maximum of 1.5 AOA Category 2-A credits and will report CME and specialty credits commensurate with the extent of the physician’s participation in this activity.
- Nurse: Des Moines University is Iowa Board of Nursing approved provider #112. This live activity has been reviewed and approved for 1.5 continuing education contact hour(s). No partial credit awarded.
- Other Healthcare Professionals: This live activity is designated for a maximum of 1.5 AMA PRA Category 1 Credit(s)™.
No ineligible company provided financial support for this continuing education activity.
The planning committee member(s) and speaker(s) will disclose if any pharmaceuticals or medical procedures and devices discussed are investigational or unapproved for use by the U.S. Food and Drug Administration (FDA). Determination of educational content and the selection of speakers is the responsibility of the activity director.
Relevant to the content of this educational activity, the following individual(s) have no conflict(s) with ineligible companies to disclose.
- Julie Baker, MPA, CHCEF - Planning Committee Member and Moderator
- Kristi Barslou - Activity Coordinator
- Mark Hillenbrand, MSW, LISW, RCSW - Planning Committee Member
- Megan Srinivas, MD, MPH - Planning Committee Member
- Megan Westerly, MSN, RN - Activity Coordinator and Moderator
Relevant to the content of this educational activity, the following individual(s) have a conflict(s) with ineligible companies to disclose. All relevant financial relationships have been mitigated.
- Steven Donnelly, PharmD - Planning Committee Member, Speaker for Gilead
- Douglas LaBrecque, MD - Planning Committee Member, Advisory Board Member for HepQuant
- Seth Owens - Speaker, Does not have a relationship with an ineligible company, but does intend to discuss off-label uses of commercial products(s)/devices(s) and agrees to inform learners of such.
The information provided at this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. The content of each presentation does not necessarily reflect the views of Des Moines University.
- 1.50 AMA PRA Category 1 Credits™
- 1.50 AOA Category 2A
- 1.50 CE Contact Hour(s)
- 1.50 IBON